Orbital Apex Syndrome caused by invasive aspergillosis in patient with post-Covid-19 infection - A case report

Abstract

Introduction and importance: Orbital Apex Syndrome (OAS) are characterized by multiple symptoms, such as impaired eye movement, periorbital pain, and visual disturbance. AS symptoms may be caused by inflammation, infection, neoplasm, or a vascular lesion, potentially involving a variety of nerves, such as the optic, oculomotor, trochlear or abducens, or the ophthalmic branch of the trigeminal nerve. However, OAS caused by invasive aspergillosis in post-COVID patient is a very rare phenomenon.

Case presentation: A 43-year-old male with a history of diabetes mellitus and hypertension who had recently recovered from a COVID-19 infection developed blurred vision on the left eye field, followed by impaired vision on left eye field for 2 months then retro-orbital pain for a further 3 months. The blurring of vision and headache developed soon after recovering from COVID-19 and was progressive in left eye field. He denied any symptoms of diplopia, scalp tenderness, weight loss, or jaw claudication. The patient was treated with IV methylprednisolone for 3 days with as diagnosis of optic neuritis, followed by a course of oral corticosteroid therapy (prednisolone, starting at 60 mg for 2 days and then tapered for 1 month), which produced transient relief of symptoms that recurred when prednisone was discontinued. Then repeat MRI was perform with no evidence of lesion; treated again in a line of optic neuritis and symptoms relief transiently. After reoccurrence of symptoms repeat MRI was perform which showed a heterogeneously enhancing intermediate signal intensity lesion in the left orbital apex. The lesion was encasing and compressing the left optic nerve, without abnormal signal intensity or contrast enhancement within the left optic nerve either proximal or distal to the lesion. The lesion was contiguous with focal asymmetric enhancement in the left cavernous sinus. No inflammatory changes were seen in the orbital fat.

Clinical discussion: OAS due to invasive fungal infection is uncommon and most often caused by Mucorales spp., or Aspergillus, particularly in those with immunocompromising conditions or uncontrolled diabetes mellitus. In OAS due to Aspergillosis urgent treatment is necessary to avoid complications such as complete vision loss and cavernous sinus thrombosis.

Conclusion: OASs, represent a heterogenous group of disorders that results from a number of etiologies. OAS in a background of COVID-19 pandemic can be due to invasive Aspergillus infection as in our patient without any systemic illness and lead to miss diagnosis and delay in proper treatment.

Keywords: Aspergillosis; Orbital Apex Syndrome; Post-Covid-19 infection.